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Ch.

57 Acute Intracranial Problems

Identify two ways the following three-volume components of intracranial pressure (ICP) can be
changed to adapt to small increases in intracranial pressure.
a. Cerebrospinal fluid (CSF)
b. Brain Tissue
c. Blood tissue

a. Increased absorption, decreased production, displacement into spinal canal


b. herniation, lesion, edema, collapse of veins and dural sinuses, increased venous outflow and
decreased blood flow
c. distention of dura, slight compression of tissue

Normal ICP ranges from:

5 to 15 mm Hg

Autoregulation to maintain constant blood flow to the brain becomes ineffective when the MAP is
below _____________, and the brain becomes ___________. Autoregulation also becomes
ineffective when MAP is greater than ___________ mm Hg because the vessels are maximally
_______________

50 mm Hg; ischemic; 150 mm Hg; constricted

CPP = MAP - ICP

Calculate the CPP of a patient whose BP is 106/52 and ICP is 14 mmg Hg.

MAP = DBP + 1/3 (SBP - DBP)= 52 + 18 = 70


CPP = 70 - 14 = 56

Cerebral ischemia and neuronal death occur when CPP is less than _________ mm Hg. A CPP less
than __________ mm Hg is incompatible with life.

50 mm Hg; 30 mm Hg

Indicate whether the following factors increase or decrease cerebral blood flow
a. Pa Co2 of 30 mm Hg
b. Pa O2 of 45 mm Hg
c. Decreased MAP
d. Increased ICP
e. Arterial blood pH of 7. 3

A. Decrease
B. Increase
C. Decrease
D. Decrease
E. Increase

Match the common causes of cerebral edema with their related types
a. Destructive lesions or trauma
b. Increased permeability of blood-brain barrier
c. Local disruption of cell membranes
d. Ingested toxins
e. Hydrocephalus

A. Cytotoxic
B. Vasogenic
C. Cytotoxic
D. Vasogenic
E. Interstitial

The earliest signs of increased ICP the nurse should assess for include
a. Cushing's triad
b. unexpected vomiting
c. decreasing level of consciousness (LOC)
d. dilated pupil with sluggish response to light

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A
decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

The nurse recognizes the presence of Cushing's triad in the patient with
a. Increased pulse, irregular respiration, increased BP
b. decreased pulse, irregular respiration, increased pulse pressure
c. increased pulse, decreased respiration, increased pulse pressure
d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla,
the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's
triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse
pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

Increased ICP in the left cerebral cortex, caused by intracranial bleeding causes displacement of
brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to
as
a. uncal herniation
b. tentorial herniation
c. cingulate herniation
d. temporal lobe herniation

C. Cingulate herniation- the dural structures that separate the two hemispheres and the cerebral
hemispheres from the cerebellum influence the patterns of cerebral herniation. A cingulated
herniation occurs where there is lateral displacement of brain tissue beneath the falx cerebri.

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the
patient is
a. aseptic technique to prevent infection
b. constant monitoring of ICP waveforms
c. removal of CSF to maintain normal ICP
d. sampling CSF to determine abnormalities

A. Aseptic technique to prevent infection- An intraventricular catheter is a fluid coupled system that
can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic
technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP
waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is
done only when specifically ordered

Metabolic and nutritional needs of the patient with increased ICP are best met with
a. enteral feedings that are low in sodium
b. the simple glucose available in D5W IV solutions
c. a fluid restriction that promotes a moderate dehydration
d. balanced, essential nutrition in a form that the patient can tolerate

D. Balanced, essential nutrition in a form that the patient can tolerate= A patient with increased ICP
is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the
brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a
patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube
feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements,
and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients
should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine
output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

The three criteria assess by the Glasgow Coma Scale (GCS) are:
A.
B.
C.

A. open eyes
B. best verbal response
C. Best motor response

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal
response except moaning and muttering when stimulated, and flexes his arm in response to painful
stimuli. The nurse records the patients GCS score as
a. 6
b. 7
c. 9
d. 11

B. 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4


Total = 7

When assessing the body function of a patient with increased ICP, the nurse should initially assess
a. corneal reflex testing
b. extremity strength testing
c. pupillary reaction to light
d. circulatory and respiratory status

D. Circulatory and respiratory status- Of the body functions that should be assessed in an
unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the
ABCs (airway, breathing, and circulation)

CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the
brainstem by
a. assessing for nystagmus
b. testing the corneal reflex
c. testing pupillary reaction to light
d. testing for oculocephalic (doll's eye) reflex

C. Testing pupillary reaction to light- One of the functions of CN III, the oculomotor nerve, is pupillary
constriction, and testing for pupillary constriction is important to identify patients at risk for
brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of
CN V and VII, and the oculocephalic reflex tests all cranial nerves involved with eye movement.
Nystagmus is commonly associatted with specific lesions or chemical toxicities and is not a definitive
sign of ICP

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral
edema. An appropriate nursing intervention for the patient is
a. avoiding positioning the patient with neck and hip flexion
b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg
c. clustering nursing activities to provide periods of uninterrupted rest
d. routine suctioning to prevent accumulation of respiratory secretions

A. Avoiding positioning the patient with neck and hip flexion- Nursing care activities that increase ICP
include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should
be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2
below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to
35 mm Hg.

An unconscious patient with increased ICP in on ventilatory support. The nurse notifies the health
care provider when arterial blood gas measurement results reveal a
a. pH of 7.43
b. SaO2 of 94%
c. PaO2 of 50 mm Hg
d. PaCO2 of 30 mm Hg

C. PaO2 of 50 mm Hg- A PaO2 of 50 mm Hg reflects a hypoxemia that may lead to further decreased
cerebral perfusion and hypoxia and must be corrected. The pH of SaO2 are within normal range, and
a PaCO2 of 30 mm Hg reflects acceptable value for the patient with increased ICP

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following
manifestations indicate an increased ICP (select all that apply)
a. fever
b. oriented to name only
c. narrowing pulse pressure
d. dilated right pupil > left pupil
e. decorticate posturing to painful stimulus

A, B, D, E- The first sign of increased ICP is a change in LOC. Other manifestations are dilated
ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate
pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with
widened pulse pressure and bradycardia

While the nurse performs ROM on an unconscious patient with increased ICP, the patient
experiences severe decerebrate posturing reflexes. The nurse should
a. use restraints to protect the patient from injury
b. administer CNS depressants to lightly sedate the patient
c. perform the exercises less frequently because posturing can increase ICP
d. continue the exercises because they are necessary to maintain musculoskeletal function

C. Perform the exercises less frequently because posturing can increase ICP- If reflex posturing
occurs during ROM or positioning of the patient, these activities should be done less frequently until
the patient's condition stabilizes, because posturing can case increases in ICP. Neither restraints nor
CNS depressants would be indicated.

Linear skull fracture

Fractured skull without alteration in fragment

Depressed skull fracture

Inward indentation of the skull with possible pressure on brain

Compound skull fracture

Depressed skull fracture and scalp lacerations with communication to intracranial cavity

Comminuted skull fracture

Multiple linear fracture with fragmentation of the bone

Basilar skull fracture

May involve dural tear with CSF otorrhea, vertigo, and Battles' sign

Posterior fossa fracture

Cortical blindness or visual field defects

Frontal lobe skull fracture

Possible pneumocranium, CSF rhinorrhea

Orbital skull fracture

Causes periorbital ecchymoses

Parietal skull fracture

May cause deafness, loss of taste, and CSF otorrhea

Cerebral concussion

Temporary, minor injury with transient reduction in neural activity and LOC

Cerebral contusion

Bruising of brain, often associated with coup-countercoup injury

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present
in the drainage, the nurse
a. examines the tympanic membrane for a tear
b. tests the fluid for a halo sign on a white dressing
c. tests the fluid with a glucose identifying strip or stick
d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis
B. Tests the fluid for a halo sing on a white dressing- Testing clear drainage for CSF in nasal or ear
drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the
blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for
a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences
a. failure to regain consciousness following a head injury
b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury
c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months
d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a
decrease in LOC

D. An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms
include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An
acute subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural
hematoma develops over weeks or months

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal
fracture with a subdural hematoma in a patient admitted to the emergency department following an
automobile accident. In planning care for the patient, the nurse anticipates that
a. the patient will receive life-support measures until the condition stabilizes
b. immediate burr holes will be made to rapidly decompress the intracranial activity
c. the patient will be treated conservatively with close monitoring for changes in neurologic
condition
d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression
of the cranium

D. When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated
to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of
acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes
may be used in an extreme emergency for rapid decompression, but with a depressed fracture,
surgery would be the treatment of choice

When a patient is admitted to the emergency department following a head injury, the nurse's first
priority in management of the patient once a patent airway is confirmed is
a. maintaining cervical spine precautions
b. determining the presence of increased ICP
c. monitoring for changes in neurologic status
d. establishing IV access with a large-bore catheter

A. In addition to monitoring for a patent airway during emergency care of the patient with a head
injury, the nurse must always assume that a patient with a head injury may have a cervical spine
injury. Maintaining cervical spine precautions in all assessment and treatment activities with the
patient is essential to prevent additional neurologic damage.

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has
return of motor control and orientation but appears apathetic and has reduced awareness of his
environment. When planning discharge or the patient, the nurse explains to the patient and the
family that
a. continuous improvement in the patient's condition should occur until he has returned to pre
trauma status
b. the patient's complete recovery may take years, and the family should plan for his long term
dependent care
c. the patient is likely to have long term emotional and mental changes that may require continued
professional help
d. role changes in family members will be necessary because the patient will be dependent on his
family for care and support

C. Residual mental and emotional changes of brain trauma with personality changes are often the
most incapacitating problems following head injury and are common in patients who have been
comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to
avoid family-patient friction and maintain family functioning, and professional assistance may be
required. There is no indication he will be dependent on others for care, but he likely will not return
to pre trauma status

Assisting the family to understand what is happening to the patient is an especially important role of
the nurse when the patient has a tumor of the
a. ventricles
b. frontal lobe
c. parietal lobe
d. occipital lobe

B. Frontal lobe- frontal lobe tumors often lead to loss of emotional control, confusion, memory loss,
disorientation, and personality changes that are very disturbing and frightening to the family.
Physical symptoms, such as blindness, disturbances in sensation and perception, and even seizures,
that occur with other tumors are more likely to be understood and accepted by the family

Burr holes

Opening into cranium with a drill to remove blood and fluid

Craniotomy

Opening into cranium with removal of bone flap to open dura

Craniectomy

Excision of cranial bone without replacementq

Cranioplasty

Replacement of part of the cranium with an artificial plate

Sterotactic surgery

Three dimensional targeting of cranial tissue

Shunt procedures

Placement of tubes to redirect CSF from one area to another

For the patient undergoing a craniotomy, the nurse provides information about the use of wigs and
hairpieces or other methods to disguise hair loss
a. during pre operative teaching
b. in the patient asks about their use
c. in the immediate postoperative period
d. when the patient expresses negative feelings about his or her appearance

A. During pre operative teaching- The prevent undue concern and anxiety about hair loss and
postoperative self-esteem disturbances, a patient undergoing cranial surgery should be informed pre
operatively that the head is usually shaved in surgery while the patient is anesthetized and that
methods can be used after the dressings are removed postoperatively to disguise the hair loss. In the
immediate postoperative period, the patient is very ill, and the focus is on maintaining neurologic
function, bur preoperatively the nurse should anticipate the patient's postoperative need for self-
esteem and maintenance of appearance.

Successful achievement of patient outcomes for the patient with cranial surgery would be best
indicated by the
a. ability to return home in 6 days
b. ability to meet all self-care needs
c. acceptance of residual neurologic deficits
d. absence of signs and symptoms of increased ICP

D. Absence of signs and symptoms of increased ICP- The primary goal after cranial surgery is
prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are
nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient
depend on the reason for surgery, the postoperative course, and the patient's general state of
health

Characteristics of meningitis

Most frequently caused by bacteria, CSF production increased, Involves an inflammation of pia
matter and arachnoid layer, has a rapid onset of symptoms, exudate may impair normal CSF flow
and absorption

Characteristics of encephalitis

Is an inflammation of the brain, may be transmitted by insect vectors, almost always has a viral
cause, cereral edema is a major problem

A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment,
the nurse questions the patient about a recent history of
a. mosquito or tick bites
b. chickenpox or measles
c. cold sores or fever blisters
d. an upper respiratory infection

D. An upper respiratory infection- Meningitis is often a result of an upper respiratory infection or


middle ear infection, where organisms gain entry to the CNS. Epidemic encephalitis is transmitted by
ticks and mosquitoes, and nonepidemic encephalitis may occur as a complication of measles,
chickenpox, or mumps. Encephalitis caused by the herpes simplex virus carries a high fatality rate

Classic symptoms of bacterial meningitis include


a. papilledema and psychomotor seizures
b. high fever, nuchal rigidity, and severe headache
c. behavioral changes with memory loss and lethargy
d. positive Kernig's and Brudzinski's signs and hemiparesis
B. High fever, severe headache, nuchal rigidity, and positive Brudzinski's and Kernig's signs are such
classic symptoms of meningitis that they are usually considered diagnostic for meningitis. Other
symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, may occur as
complications of increased ICP and cranial nerve dysfunction.

Vigorous control of fever in the patient with meningitis is required to prevent complications. Identify
four undesirable effects of fever in the patient with meningitis

1.increased seizures
2. increased ICP
3. dehydration
4. direct neurologic damage

On physical examination of a patient with headache and fever, the nurse would suspect a brain
abscess when the patient has
a. seizures
b. nuchal rigidity
c. focal symptoms
d. signs of increased ICP

C. The symptoms of brain abscess closely resemble those of meningitis and encephalitis, including
fever, headache, and increased ICP, except the patient also usually has some focal symptoms that
reflect the local are of the abscess.

Vasogenic cerebral edema increases ICP by


a. shifting fluid in gray matter
b. altering the endothelial lining of cerebral capillaries
c. leaking molecules from the intracellular fluid to the capillaries
d. altering the osmotic gradient flow inot the intravascular component

B. Altering the endothelial lining of cerebral capillaries

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure
reflects
a. a severe decrease in cerebral perfusion pressure
b. an alteration in the production of CSF
c. the loss of autoregulatory control of ICP
d. a normal balance between brain tissue, blood, and CSF

D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg

The nurse plans care for a patient with increased ICP with the knowledge that the best way to
position the patient is to
a. keep the head of the bed flat
b. elevate the head of the bed to 30 degrees
c. maintain patient on the left side with the head supported on a pillow
d. use a continuous rotation bed to continuously change patient position

B. elevate the head of the bed to 30 degrees

The nurse is alerted to possible acute subdural hematoma in the patient who
a. has a linear skull fracture crossing a major artery
b. has focal symptoms of brain damage with no recollection of a head injury
c. develops decreased LOC and a headache within 48 hours of head injury
d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC

C. develops decreased LOC and a headache within 48 hours of head injury

During admission of a patient with a severe head injury to the ED, the nurse places highest priority
on assessment for
a. patency of of airway
b. presence of a neck injury
c. neurologic status with Glascow Coma Scale
d. CSF leakage from ears and nose

A. Patency of airway is the #1 priority with all head injuries

A patient is suspected of having a cranial tumor. The signs and symptoms include memory deficits,
visual disturbances, weakness of right upper and lower extremities, and personality changes. The
nurse recognizes that the tumor is most likely located in the
a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe

A. Frontal lobe

Nursing management of a patient with a brain tumor includes (select all that apply)
a. discussing with the patient methods to control appropriate behavior
b. using diversion techniques to leep the patient stimulated and motivated
c. assisting and supporting the family in understanding any changes in behavior
d. limiting self care activities until the patient has regained maximal physical functioning
e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs.

C, E

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?
a. patient with a skull fracture whose nose is bleeding
b. elderly patient with a stroke who is confused and whose daughter is present
c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale
d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had
continued emesis

C. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale

A nursing measure that is indicated to reduce the potential for seizures and increased ICP in the
patient with bacterial meningitis is
a. administering codeine for relief of head and neck pain
b. controlling fever with prescribed drugs and cooling techniques
c. keeping the room darkened and quiet to minimize environmental stimulation
d. maintaining the patient on strict bed rest with the HOB slightly elevated

B. Controlling fever with prescribed drugs and cooling techniques